Intermittent catheterization is the mode of bladder management generally associated with the fewest long-term complications (Groah et al. 2002; Weld & Dmochowski 2000; Ord et al. 2003). However, there are some complications that occur with higher frequency in patients who intermittently catheterize. For example, increased urethral complications (19% incidence) may lead to urosepsis and epididymorchitis (28.5% incidence) and may result in increased morbidity and reduced fertility (Ku et al. 2006). Despite IC-related higher rates of complications, there is good consensus among the larger retrospective studies available that IC programs are still preferred for the protection of the upper urinary tract through regular emptying with low bladder pressures (Giannantoni et al. 2001). Episodes of pylonephritis and UTI are also reduced when bladder emptying is conducted consistently and completely in the absence of indwelling catheters (Groah et al. 2002; Weld & Dmochowski 2000; Ord et al. 2003; Giannantoni et al. 2001; Woodbury et al. 2008).
Perrouin-Verbe et al. (1995) showed that patients most likely to continue with IC would be those who are able to independently catheterize and those who have an acceptable level of continence. In line with this finding, Pannek and Kullik (2009b) showed that in patients who employ self-IC and have optimal bladder function, perceived QoL is higher than those with suboptimal function. Akkoc et al. (2013) compared individuals using various bladder management methods; those with normal spontaneous micturition had the highest QoL whereas those using an attendant to perform IC had the lower QoL. The authors reported, however, that there was no difference in personal relationships, general health perception, and sleep/fatigue among groups. These findings are in contrast to those by Oh et al. (2006) who found significant differences in many variables measured by the SF-36 between individuals with SCI and able-bodied controls. It is essential to consider an individual’s activities of daily living, psychological factors (and other concurrent comorbidities) and potential caregiving needs when IC is being introduced early after SCI.
A very low incidence of bladder stones and hydronephrosis were reported in Perouin-Verbe et al. (1995; 2%), consistent with previously discussed studies. However, Nanninga et al. (1982) reported upper tract changes in 33% of patients. While this range is large, it is possible that management of patients in 1982 involved less stringent control of high bladder pressures which is the cause of upper tract disease in many cases (Nanninga et al. 1982). Nanninga noted that high bladder pressures may occur even in patients who remain continent or nearly continent between catheterizations, and that the problem can at least be partially avoided by increasing the frequency of catheterization. Other options for patients with persistently elevated pressures already on IC programs are detrusor OnaBTx injections and/or anticholinergic medications. It is important to note that regular follow-up of these patients including tests of bladder physiology and upper tract function is recommended to monitor for changes and for increasing incidence of complications with time (Perrouin-Verb et al. 1995; Nanninga et al. 1982).
Finally, in a small RCT, Polliak et al. (2005) used a portable ultrasound device to measure bladder volumes among a group of individuals post SCI. Compared to those who used time-dependent IC, those using volume-dependent IC had significantly fewer catheterizations which resulted in a significant reduction in cost (p<0.001).
There is level 4 evidence (from many non-randomized controls) that urethral complications and epididymoorchitis occurs more frequently in those using IC programs for bladder emptying, but the advantages of improved upper tract outcome over those with indwelling catheters outweigh these disadvantages.
There is level 1b evidence (from one RCT: Polliack et al. 2005) that using a portable ultrasound device reduces the frequency and cost of intermittent catheterizations.